JOURNAL OF PALLIATIVE MEDICINE

Volume 12, Number 4, 2009

Mary Ann Liebert, Inc.
DOI: 10.1089=jpm.2009.9645

Pioneers in Palliative Care

Feature Editor: Vyjeyanthi S. Periyakoil

Change Management: The Secret Sauce of Successful

Program Building
Vyjeyanthi S. Periyakoil, M.D.

he field of palliative care is somewhat counterculture to mainstream biomedicine. In conventional biomedicine, symptoms are used merely as a means to an end,
i.e., symptoms are used as clues to diagnose the underlying
culprit, the disease. Once identified, all energy is devoted to
annihilating the culprit. In contrast, in the field of palliative
care, the symptom (pain, dyspnea, nausea, etc.) itself is the
focus and much effort is directed at alleviating the symptom.
Understandably, this premise of palliative care sets it apart
from the rest of mainstream biomedicine. Additionally, hospice and palliative medicine being the newest kid on the
block of medical subspecialties fundamentally represents
change. Therefore, effecting and sustaining change is a key survival skill for all palliative care professionals.
Effecting change is a process (not an event) and requires
both strategic thinking and ongoing hard work. The Center
for Advancement of Palliative Care (CAPC) founded by the
pioneering efforts of Dr. Diane Meier offers a framework,
requisite tools, and support for clinicians who want to
change their local health care systems for the better by
building new and expanding existing palliative care programs.1 Additionally, clinicians have to become skilled in
the process of change management in order to harness the
full power of the CAPC tools to create successful palliative
care programs.

Decide What to Do


Step 3: Develop a vision and strategy: A vision can be

defined as a desired realistic and credible future state that
an organization hopes to achieve. An effective vision is a
compelling dream that energizes the project team and
provides both the emotional and intellectual energy for the
series of actions that will ultimately result in the actualization of the vision. The team should write a brief vision
statement and also identify the concrete tasks to be done to
get closer to the vision.

Make it Happen

Kotters Eight-Step Model for Change Management

Change management is a stepwise approach for ensuring
that programmatic changes are implemented smoothly and
systematically and that the lasting benefits of change are
achieved. One of the most effective and widely used change
management models was developed by John Kotter at the
Harvard Business School.2 The Kotter model outlined below
serves as a successful roadmap and can be used to operationalize any of your palliative care initiatives.

Set the Stage



poor observed-to-expected mortality ratios for hospitalized

patients) and compelling patient case studies are two effective tools that will typically galvanize stakeholders into
supporting your palliative care initiative.
Step 2: Create a coalition for change: Identify the true
leaders=champions in your organization. Champions are
people whose power and influence may come from a variety of sources, including job title, status, expertise, political importance, community connections, and special
skills. Securing commitment=endorsement from and
scheduling regular brief meetings with these champions
will build collegiality and a common purpose that can be
harnessed to create buy-in for the project.

Step 1: Establish a sense of urgency: It is not that people

are incapable of seeing the solution. Often people are incapable of seeing the problem. Once convinced that the
problem does exist, most people are willing to adopt reasonable solutions. Local institutional data (for example:

Stanford University School of Medicine, Stanford, California.

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Step 4: Communicate the change vision to others: The

project team should assiduously look for and articulate the
vision speech at every available formal and informal opportunity in order to secure stakeholder buy-in. The more
the vision is publicized over time, the more effective it
becomes.
Step 5: Identify and overcome resistance: Any change
initiative will always run into human resistance. Diagnosing and overcoming resistance is the backbone of
change management. Overcoming resistance will serve to
empower the people you need to execute the vision.
Education, negotiation, and persuasion are the most effective tools in overcoming resistance to change. The palliative care communication skills that we use so successfully
on patients and families are just as effective when used on
colleagues and coworkers.

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Step 6: Generate short term successes: Nothing succeeds

like success. The project team needs a taste of victory quite
early in the change process. It is therefore critical to identify low-hanging fruit (simple and surefire milestones
with little room for failure) and achieve them as a demonstration of the credibility and validity of the proposed
initiative. Small and early successes will feed on themselves to create sufficient momentum and morale to overcome the perils and pitfalls related to the project.
Step 7: Consolidate gains and produce more change:
Kotter states that many change projects fail because small
wins are confused for enduring victory. Enduring change
needs to overcome organizational cultural resistance and
this process takes time and effort. With every project
milestone achieved (or failed), it is important to analyze
and learn from the outcomes. It is also important to preserve and augment the momentum by recruiting new stake
holders and celebrating successful project milestones.

Make it Stick


Step 8: Anchor the changes in the institutional culture:

Finally, the change has to be hardwired into the core of
your organization. The healthcare environment is ever
changing, with staff turnover, influx of new initiatives and
shifting organizational priorities. Incorporating the initiative into local protocols and procedures and adopting a
reminder system are two effective strategies to weave the
change into the organizational fabric. Finally, anything
worth doing is also worth measuring. Brief surveys (colleagues and stakeholders as well as patients and families)
that can be tailored to focus on specific features that are
most relevant to the new initiative are the most commonly
used metrics. Sharing project data with stakeholders fur-

PERIYAKOIL

ther serves to bring in new streams of energy and resources.

Our lives are not the only ones that are affected by what is
happening to us and what we are doing at work. Everyone
in our work lives (friends, co-workers, subordinates, supervisors) are touched in some way by what we do. Most
importantly, the more we incorporate palliative care into
our organizations and effect change, the more we enable
and empower those around us to change for the better. Lao
Tzu the ancient Chinese philosopher eloquently summarizes this process as:
Learn from the people
Plan with the people
Begin with what they have
Build on what they know
Of the best leaders
When the task is accomplished
The people all remark
We have done it ourselves.

References
1. Meier D: Finding my place. J. Palliat. Med 2009;12:331335.
2. Kotter JP: Leading change. Harvard Bus Rev 2007;85:96103.

Address reprint requests to:

Vyjeyanthi S. Periyakoil, M.D.
Stanford University School of Medicine
3801 Miranda Avenue
100-4A
Palo Alto, CA 94304
E-mail: periyakoil@stanford.edu